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Could Simultaneous Nasal and Oral Irrigation Be a Nontherapeutic

Tool against SARS-CoV-2?
Bharat Baruah*

Cite This: https://dx.doi.org/10.1021/acschemneuro.0c00740 Read Online

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ABSTRACT: For the last 8 months, COronaVIrus Disease 2019 (COVID-19) has been hovering over the planet as a pandemic,
and there is no sign of this virus going away anytime soon. In the meantime, life must go on, businesses must remain open,
manufacturing must flow smoothly to fulfill consumers’ daily demands, and education cannot be halted. Simultaneously, the frontline
workers like doctors, nurses, support staff, and other essential workers are working tirelessly in their respective fields in the absence
of a widely available effective vaccine. The question is: What should every citizen who needs to venture out to fulfill their daily
business do in addition to wearing a mask, handwashing, and physical distancing? Could we add simultaneous nasal and oral
irrigation as a nontherapeutic practice to our personal care list as an additional preventative layer?
KEYWORDS: COVID-19, pandemic, nasal irrigation, oral irrigation, personal care, viral load

A s of December 2, 2020, severe acute respiratory syndrome

coronavirus-2 (SARS-CoV-2), which causes COronaVIrus
Disease 2019 (COVID-19), has infected almost 65 million and
claimed 1.5 million lives worldwide. The World Health
Organization (WHO) and the Center for Disease Control and
Prevention (CDC) work with other public health partners to
minimize the impact globally, considering the seriousness of the
pandemic. The virus has devastated many businesses in terms of
economic impact, and some have disappeared forever. Yes, some
new companies emerged at the same time, and some are
flourishing as a result of the pandemic. Some technology
companies realized that they could function smoothly without
even providing their employees with office space. High school
and college students graduated without a traditional graduation
ceremony; newly admitted college students have not seen the
college campus yet. The consumer psychology and economic
effects of COVID-19 are vast and worldwide. Among all these
changes, the government had to open up schools and businesses
to keep the economy going with specific public health
guidelines. Among these, mandating masks in public places,
frequent handwashing, and maintaining a 6 ft distance are the
critical health practices for everyone to follow.
Since the start of the pandemic, scientists worldwide have
been working day and night to develop a vaccine. Several of
them are now in phase three clinical trials. Pfizer and its partner
BioNTech announced that their recent vaccine in the phase
three trial shows some results exceeding the initial expectation
and is up to 95% effective. However, it is not yet clear if the
vaccine can prevent severe cases that cause hospitalization or if it
can prevent the population from carrying the virus that causes
COVID-19 without symptoms. On November 16, 2020, the
biotech company Moderna Inc. announced that its experimental
vaccine is 94.5% effective in preventing disease, according to its
clinical trial analysis. Both vaccines work based on a molecule
known as mRNA, or messenger RNA. However, the Pfizer
vaccine has a significant distribution hurdle due to the
Received: November 18, 2020
Accepted: December 3, 2020

© XXXX American Chemical Society https://dx.doi.org/10.1021/acschemneuro.0c00740

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Figure 1. Schematic representation of the (A) nasal and oral cavity, (B) nasal cilia covered with mucus and allergens, (C) clean nasal cilia after the nasal
irrigation, (D) front and side view of the nasal cavity during nasal irrigation and the direction of liquid flow, and (E) side view of the nasal and oral cavity
during nasal and oral irrigation and direction of liquid flow.
requirement of specialized ultracold freezers capable of cooling
below −94 °F (−70 °C) for the storage of the vaccine, even
though Pfizer claims that this is manageable. In contrast, the
Moderna vaccine can be safely stored in freezers at about 25 °F
(−4 °C). Even a home freezer can reach and maintain this
temperature. If the vaccine is approved, Pfizer is projecting to
produce 50 million doses globally by the end of 2020. In the year
2021, it could be 1.3 billion. Moderna hopes to be able to deliver
∼20 million vaccine doses in the United States by the end of
2020. By next year, it expects to generate 500 million to 1 billion
doses worldwide.
In the meantime, what could be the civic duty of the general
population to minimize the spread of the virus while performing
their day-to-day human activities as professionals or as civilians?
Do we depend on the mask, physical distancing, and frequent
handwashing alone? Are there any additional steps for us?
Handwashing was there for us anyway as a rule of thumb for
personal hygiene. Could we, as responsible citizens, take a few
extra personal care steps that may enhance health conditions?
According to Our World in Data, 2020, in the United States,
men spent 637 min per day on personal care on average, whereas
for women the average was 659 min. The statistics are based on a
questionnaire, and the age group was 15−65 years. The data
were normalized to 1440 min per day. In this survey, personal
care includes eating and drinking, sleeping, medical care, and any
travel related to personal care. Now the question is: considering
the COVID-19 pandemic, could it be possible for us to add one
more respiratory etiquette in the toolkit of personal hygiene
besides a mask, frequent handwashing, and physical distancing,
such as simultaneous nasal and oral irrigation?
Nasal irrigation (NI) is an ancient Ayurvedic medical
tradition1 that originated in India and is about cleaning the
upper respiratory tract.2 Saline nasal irrigation (SNI) (see Figure
1) is a frequently recommended nonpharmacological practice
for the treatment of chronic rhinosinusitis (CRS).3 In such a
treatment, an isotonic (0.9%) or hypertonic (2.12%) saline
solution is utilized.3 The human body’s upper respiratory system
is the entry portal for the SARS-CoV-2 virus. The virus enters via
the nose (or by mouth if we breathe by mouth) as a virus-loaded
pubs.acs.org/chemneuro Viewpoint
aerosol floating in the air is released by an infected person. The
nasal cavity lines, also known as the nasal mucosa, constitute an
unfortified area for the coronavirus to attach due to its mucinous
glands that create humid conditions and have abundant blood
vessels. The conventional human coronavirus initially attaches
to the ciliary dyskinesia and the ciliated epithelium and weakens
mucociliary clearance.4 Such harm to the respiratory epithelium
by the coronavirus often occurs without symptoms. Hence,
taking personal preventative care of the upper respiratory system
is of utmost importance before acute conditions arise, or even
before the virus attacks the lower respiratory system.
SNI is a nonpharmacological practice known to remove
antigens, biofilms, bacteria, and viruses from nasal mucosa and
improve mucociliary activity.4 A daily SNI practice could
minimize the viral load in the nasal cavities. In a typical SNI
procedure, a neti pot or a squirt bottle is used for flushing saline
into the right nasal opening and allowing the saline to come out
through the left nasal opening, as shown in Figure 1D. This
procedure is repeated with the left nostril. This procedure is
relatively easy after some practice, and saline flow is primarily
dictated by gravity or air pressure depending upon the neti pot
or squirt bottle. However, the upper respiratory system
constitutes both the nasal and oral cavity which interconnected
(see Figure 1A). Simultaneous saline irrigation of both the nasal
and oral cavity could be more beneficial in minimizing the virus
load in the upper respiratory system. In this procedure, the saline
solution is gently sniffed upward via both nostrils and spit out of
the mouth. One has to be careful that both nostrils are immersed
in the saline solution while performing this procedure and not to
let air into the nasal pathway (see Figure 1E) at that moment to
avoid air bubbles. One should also be careful not to swallow the
saline solution while performing the procedure. At first, the
method may seem a little uncomfortable; however, daily practice
brings ease of use. The most significant advantages of this
procedure are (i) one does not need a neti pot or a squirt bottle;
a simple 16-ounce cup would suffice, and (ii) the process
simultaneously floods the nasal and oral cavities and would
minimize the viral load. A simultaneous nasal and oral irrigation
could offer an additional shield to the individual who might be
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exposed to an asymptomatic coronavirus carrier; alternatively, (2) Principi, N., and Esposito, S. (2017) Nasal Irrigation: An
suppose an individual is infected but asymptomatic. In that case, Imprecisely Defined Medical Procedure. Int. J. Environ. Res. Public
daily simultaneous nasal and oral irrigation could keep a lower Health 14 (5), 516.
virus load in the upper respiratory system and keep family and (3) Casale, M., Moffa, A., Cassano, M., Carinci, F., Lopez, M. A.,
Trecca, E. M. C., Torretta, S., Rinaldi, V., and Pignataro, L. (2018)
friends safe. Saline nasal irrigations for chronic rhinosinusitis: From everyday
A recent study5 indicated that a type of cell, phagocytes, can practice to evidence-based medicine. An update. Int. J. Immunopathol.
engulf microbes and destroy them by producing hypochlorous Pharmacol. 32, 205873841880267.
acid (HOCl). These cells typically produce HOCl from (4) Casale, M., Rinaldi, V., Sabatino, L., Moffa, A., and Ciccozzi, M.
hydrogen peroxide and chloride ions (Cl−) with the help of (2020) Could nasal irrigation and oral rinse reduce the risk for COVID-
the enzyme myeloperoxidase. The primary antibacterial/ 19 infection. Int. J. Immunopathol. Pharmacol. 34, 205873842094175.
antiviral property in bleach is due to the active ingredient, (5) Ramalingam, S., Cai, B., Wong, J., Twomey, M., Chen, R., Fu, R.
HOCl. In general, the nonmyeloid cells cannot produce HOCl M., Boote, T., McCaughan, H., Griffiths, S. J., and Haas, J. G. (2018)
in the absence of the enzyme myeloperoxidase.5 However, it has Antiviral innate immune response in non-myeloid cells is augmented by
been demonstrated that fibroblast and epithelial cells can have chloride ions via an increase in intracellular hypochlorous acid levels.
Sci. Rep. 8, 13630.
significant antiviral properties in the presence of augmented
sodium chloride (NaCl) concentrations.5 The results in this
study suggested that nonmyeloid cells such as epithelial cells
may bear a natural antiviral activity at a particular Cl−
concentration and can produce HOCl.5 Based on these results,
one may suggest that simultaneous nasal and oral irrigation with
the saline solution could be far more beneficial against
coronavirus as the abundant Cl− ion may augment the formation
of antiviral HOCl (at a quantity that is harmless to the person
but could damage the virus cells) and also may wash off the viral
load from the nasal and oral cavity.
In summary, evidence suggests that SNI could be a safe, easy,
and cheap line of defense against human coronavirus. In the
event of a recent viral surge, the fast approaching holiday season,
possible close gatherings with family and friends, and the
absence of a widely available vaccine, civilians could adopt NI or
preferably simultaneous nasal and oral irrigation with saline
solution as a respiratory etiquette. No large population clinical
trial data is available to support that nasal and oral irrigation
could prevent the spread of the COVID-19 pandemic. However,
the adoption of this nonpharmacological personal care
technique could minimize the viral load in the upper respiratory
tract and pose no known side effects or complications. A
simultaneous nasal and oral irrigation practice twice a day could
reduce the possibility of releasing “virus loaded droplets” into
the air and significantly cut down the respiratory virus’s spread,
almost like handwashing reduces the spread of microbes from
surface to surface. As we live on a microbial planet, the
implication is that the evolution of new respiratory viruses is not
unlikely in the future; having this respiratory etiquette in our
daily routine might help keep the bugs at bay.

■ AUTHOR INFORMATION
Corresponding Author
Bharat Baruah − Department of Chemistry and Biochemistry,
Kennesaw State University, Kennesaw, Georgia 30144-5591,
United States; orcid.org/0000-0001-9988-2899;
Phone: +1 470 578 2654; Email: bbaruah@kennesaw.edu;
Fax: + 1 470 578 9137
Complete contact information is available at:
https://pubs.acs.org/10.1021/acschemneuro.0c00740

Notes
The author declares no competing financial interest.

■ REFERENCES
(1) Rama, S., Ballentine, R., and Hymes, A. (1998) Science of Breath: A
Practical Guide, Himalayan Institute Press: Honesdale, PA.

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